Health risks caused by heavy metal (HM) exposure in road dust has attracted extensive attention, but few studies have focused on the health risks of residents living in small- and medium-sized cities with rapid industrialization and urbanization. Thus, 140 road dust samples were collected across Anyang, a typical fourth-tier industrial city in central China, which were analysed for 10 different HMs (Mn, Zn, Pb, V, Cr, As, Cd, Ni, Cu and Co). Monte Carlo simulation and bioaccessibility were used to quantify the health risks of heavy metals comprehensively in road dust. Results revealed a remarkable accumulation of Mn, Zn, Pb, Cd and Cu. According to the Geo-accumulation index and potential ecological risk index, Cd was priority control pollutant. Moreover, 55.0% of the road dust samples reached heavily polluted level, and 52.86% of the samples were at high ecological risk levels. These results illustrated that HM contamination was serious and universal in the road dust of Anyang. The occurrences of HMs were allocated to traffic emissions, natural sources, industrial activities and agricultural activities with contribution rates of 35.4%, 6.0%, 41.6% and 17.0%, respectively. Except for Zn in the gastric phase, all other HMs had relatively low bioaccessibilities in the gastrointestinal system, usually less than 20%. The bioaccessibilities of most HMs were higher in the gastric phase, except for Cr, Ni and Cu, which remained higher in the intestinal phase. The non-carcinogenic risk and carcinogenic risk were remarkably reduced when considering the HM bioaccessibilities in the gastrointestinal system, especially for adults. The outcomes of this paper are valuable for understanding HM contamination in road dust and highlight the importance of risk assessment for populations living in the fourth- and fifth-tier cities.